lifestyle

• 30-120 minutes exercise a day ,
• moderate alcohol consumption only,
• avoid obesity if possible,
• balanced diet including
• 9 portions of vegetables or fruit a day (9 for men, 7 for women),
• minimal of animal or 'hard' vegetable fats,
• low salt, see the evidence
  Alcohol should be limited to one drink or unit a day, six days a week (Mukamal 2004). More than this leads to brain damage.
• Oily fish such as sardine, salmon, tuna, trout, at least twice a week (small amounts are fine...not a whole salmon!).
• Fibre and healthy fats in the diet slows down retinopathy. No transfats and minimal saturated fat.

blood pressure

• 130/80 (see graph) or preferably less
• (120/75 ..home monitoring)
• 125/75 or less if protein in urine present (115/70.. home monitor)
• ACE inhibitors or Angiotensin Receptor Antagonists unless young/pregnant/very low blood pressure/poorly tolerated
• The lower the better in macular oedema, as long as you feel well.
• An ideal pressure is below 115 (systolic, first number) for healthy people. <120 is is only suitable for new/well diabetes patients 2012. Otherwise slightly higher as above.
• Home monitoring blood pressures should be 10mmHg (systolic) and 5mmHg (diastolic) lower see than these 'clinic' pressures.

HbA1c

• 7.5-6.5% or less (see graph) with very few or preferably no hypos. These (or slightly lower) levels are the best to prevent complications
• <7.5 for insulin users; <6.5 if not using insulin and have good health. Problems with intensive control.
• If hypos develop, seek expert advice from your diabetes nurse/doctor.
• if your HbA1c is high (say 11%), then the next step may be to achieve 9%....in other words, and any improvement is helpful, gradually reaching lower levels above.

sudden decrease in HbA1c

• A sudden improvement in control (HbA1c drop of 3%) will lead to a temporary rapid increase in progression of retinopathy: laser may be needed.
• Good control is important in the longer term, that is after about 2 years. When people who control their diabetes well will be better off after this period. See
• A temporary increase in retinopathy is most common when starting insulin for the first time, especially if the diabetes is very badly controlled when you start the insulin.

cholesterol

• <4.5 mmol/l, and statins recommended for most adult patients with diabetes whatever the cholesterol.
• statins are recommended whatever the cholesterol, if well tolerated age>40y
• A fibrate such as fenofibrate may be advisable in every person with exudative maculopathy. They reduce retinopathy progression 40% (Fenofibrate 200mg od) Field Study. We now recommend these for all adult patients, and they can be used in addition to a statin.
• LDL <2

smoking

• smoking   20 a day triples/quadruples retinopathy
• passive smoking may double retinopathy: room-mates inhale at least 25%

insulin

• multiple dose insulin, using a protocol such as using lantus (long acting) and rapid acting (novarapid/humalog) is normally superior to twice daily. (This is controversial.)
• Insulin pumps generally produce better control still, but are harder to use.

education

• everyone with diabetes should attend an education course, such as DAFNE (insulin) , DESMOND (type 2 at diagnosis), or XPERT (type 2). Primary Care Trusts are obliged to send you on such a course, but very few patients have ever attended one. If you have not been on one, discuss this with your diabetic team. Get a diabetes buddy.

sleep apnoea

• this contributes to macular oedema and loss of sight (Schwartz, 2006), and many serious problems.
• It is common in diabetes, particularly if you are overweight. Do you have sleep apnoea?

glucose level

• 5.0-7.2 mmol/l before meals
• <10.0 mmol/l after meals
• no serious hypos

Glitazones

• Rosiglitazone and pioglitazone should not be used if there is significant retinopathy, and certainly not if macular oedema is present, as  they increase macular oedema and fluid retention. Case 49.  Lirglutadite and Exenatide are drugs that can be used instead low also lower weight (they are injections.)

hypoglycaemia

neuropathy

issues

Grow model for coaching

• Goal
  • what is the goal?
  Reality
  • what is happening now?
  Options
  • what are the options?
  Will
  • what are you going to do?
  • what is your commitment (scale 1-10)?
  • what support do you need?
• links
• www.mentoringforchange.co.uk

7 step change model

1. building rapport..chat
2. semi-open questions, e.g...what brings us here today?
3. explore solution patterns
   1. previous attempts
   2. successful changes in other areas
4. Miracle question..how would things be different if the problem was sorted
5. scaling questions...where would you say you are at present?
6. feedback, complimentary only...." I was struck by your many insights and previous ways of dealing  with difficulties"; and so on.
7. task setting
8. link